The system of medical health care delivery in the United States is facing a critical point in its evolution. The escalating cost of health care, marked variation in the practice patterns of physicians, the increasing number of uninsured or under-insured individuals and the dissatisfaction of the public with the current health care system in this country have all contributed to the crisis currently faced by health care benefit providers. The root of the current crisis is best analyzed from an historical perspective.
The structure of organizations responsible for providing medical insurance benefits has shifted over the course of time from local providers to more complex managed health care systems of providers. The administrative structure developed to support health care providers has also grown more complex and has assumed oversight responsibilities. One of these responsibilities is the quality assessment of health care services.
Previously, if health care providers assessed the quality of health care services received by patients, they generally did so by "incident reporting" in which quality problems were identified by isolated report or individual case inquiry. Quality assessment with respect to medical practice patterns of physicians was based on the traditional method of peer review of medical records. These methods, however, are labor-intensive and inefficient. As health care organizations grew, new avenues for evaluating quality of care were explored.
More sophisticated data systems were developed to assist health care organizations, but these focused predominantly on the collection of financial data. These systems were designed to track the cost of health care by reporting actual cost incurred. While these prior art systems performed adequately for these simpler accounting and administrative functions, they became increasingly inadequate to meet the needs of the more complex managed health care systems.
The prior art health care management systems lacked organized health care data bases and evaluation methods, which permit evaluation of comprehensive health care delivery. Purchasers, providers and administrators have lacked the ability to measure and identify quality of care problems with efficiency and inclusive of whole populations receiving services. In prior art health care management systems, quality issues were generally revealed by inference in conducting utilization reviews, case management or financial analysis or in restricted areas, such as inpatient care only. This is in contrast to the direct study of quality and/or access, two factors that are presently considered crucial to the proper evaluation of health care delivery systems, and in distinction to evaluating comprehensive health care spanning inpatient and outpatient services. Management that is cost-effective, whether performed by physicians in direct patient care or administrators of managed health care systems, necessitates the collection and integration of information on the health care process, appropriateness of the medical intervention, and effectiveness, viewed in terms of outcomes. To maximize the availability and use of such information for large scale health care evaluation, it should be collected from standardized data. Through the use of such data, comparisons between actual clinical practice and authoritative practice guidelines can be made to identify opportunities to improve health care delivery and health outcomes.
Current practices of quality of care assessment depend primarily on the review and evaluation of medical records, which is costly, intrusive and not conducive to the evaluation and reporting of care delivered to large patient populations, except on a sampling basis. Medical records also may not include full pertinent information on utilization of vital services, such as laboratory or pharmacy services. In addition, current practice often focuses on placing blame on the provider, which fosters resistance by physicians to quality of care assessments, and neglects the need to consider the role of patients, purchasers and health care organizations in quality of health care. Further, current practices concentrate on merely monitoring performance without giving sufficient attention to concrete steps for improving the quality of care received by patients.
The existence of managed health care systems providing reimbursement for health care services to medical professionals, hospitals and pharmacies has led to the building of large collections of data reflecting the payment (and in some cases, the denial of payment) of claims made by individuals who are members of a managed health care plan. However, because these data are collected for financial purposes, they have not been organized or coded in a fashion that permits them to be used readily for purposes other than cost analysis. In particular, these data have not usually been used as a source of information for evaluating the quality of health care provided. Yet these data are frequently maintained on computers and, for health care systems that have several years of experience with significant participant populations, these data report, on a relatively reliable basis, the occurrence of a large number of health care services transactions for a wide variety of medical conditions, including inpatient, outpatient and pharmacy transactions.
A quality of health care screening system designed for complex managed health care systems, using the significant historical databases of claims records for the evaluation of and reporting on appropriate delivery and receipt of health care services would be a decided improvement over the prior art.